Arkansas State Department of Education/Health

Form #227 (NEW FORM NUMBER 07-08)

ARKANSAS STATE DEPARTMENT OF EDUCATION/HEALTH HEALTH HISTORY DEVELOPED BY A COMMITTEE OF THE ARKANSAS HEALTH CARE ACCESS COUNCIL

NOTE: To be completed by the parent/guardian of the Kindergarten student prior to the physical examination/nursing assessment (please print).

Student Name (Last, First, Middle) Birth Date School Medicaid Number (MO./DAY/YR.) / / Medicaid Physician

Parent/Guardian Name (Male) Phone Parent/Guardian Name (Female) Phone

Physician Name and Address (If no regular physician, write “None”) Phone

Dentist Name and Address (If no regular dentist, write “None”) Phone

Other source(s) from which the student receives health care (If none, write “None”) Phone

Name and address of private health insurance carrier:

To be completed by parent/guardian (please circle one):

1. Does your child pay attention when being read to? Yes No

2. Can your child play quietly alone for over a ½ hour? Yes No

3. Does your child mind adults and follow instructions? Yes No

4. Does your child speak clearly enough for other to understand? Yes No

5. Does your child have any speech problems (stammering, delayed Yes No

6. Does your child object to being left with a sitter Yes No Form #227 (NEW FORM NUMBER 07-08)

7. Can your child dress without help? Yes No

8. Does your child ever wet or soil him/herself during the day Yes No

9. Do you have any concerns about your child’s general health (eating and sleeping habits, bowel or bladder, posture, teeth, skin, weight, etc.)? Yes No

10. Does your child have any eye problems (difficulty seeing, crossed eyes, frequently reddened or watery eyes, wear glasses or contact lenses)? Yes No

11. Does your child have any ear or hearing problems (frequent earaches, difficulty hearing, draining ear, use a hearing aid, etc.)? Yes No

12. Does your child have any allergies (foods, insects, drugs, pollens, etc.)?Yes No

13. Does your child have any specific sickness which might in your opinion affect his school performance or program? Yes No

a) Has your child received any medical or other evaluation, the findings of which could help school personnel in meeting his/her health or educational needs? Yes No

b) Does this problem require any health care in the school? Yes No

c) Does your child take medications? Yes No

14. Do you have any concerns about your child’s developmental behavior or emotional well being of which the school should be aware? Yes No

If you answered YES to any of the preceding questions, please describe the problem or concern you have below:

Question Number Description Form #227 (NEW FORM NUMBER 07-08)

Information on this form may be shared with appropriate personnel for health and educational purposes.

Parent’s Signature______Date______